Harm Reduction as an Alcohol-Prevention Strategy

Harm-reduction programs, first developed in an attempt to mitigate the adverse consequences of illicit drug use, can be applied to alcohol-prevention programs as well. In fact, the movement toward harm reduction in illicit drug prevention may be closely paralleled by a similar trend in the alcohol-prevention field. Harm-reduction approaches to alcohol aim to diminish the negative consequences of intoxication (e.g., by using special glassware that breaks into fine particles instead of sharp pieces, thus reducing the chance of injury during pub fights). Such measures may receive increased attention as public support declines for restrictions on alcohol availability and new evidence emerges on the potential benefits of moderate alcohol consumption. In addition, analyses suggest that harm reduction may be an efficient approach, because it often focuses on minimizing heavy-drinking occasions, which predict drinking problems more strongly than level of consumption.

. Despite the programs' success-or perhaps because of it-the harmreduction movement is now at a crucial cross roads. The c once pt of harm reduc ti on lacks a clear, uniformly accepted definition, yet such a definition is necessary as harm reduction garners increased attention. Not only are harmreduction approaches being implemented in a greater number of geographical areas, but the concept also is expanding in terms of its ac ceptance on official levels (e.g., it is currently the basis of Canada's Drug Strategy) and its scope. Harm reduc tion has extended beyond the goal of slowing the spread of AIDS and other communicable diseases (O'Hare 1992). Now programs aimed at ameliorating the consequences of both licit and il licit drug use are described as "harm reduction" (for example, see Plant et al. 1996), and the concept has been applied to alcoholprevention programs as well. This article contends that the trend toward using harmreduction approaches in illicit drug prevention strategies closely parallels several pro gressive alcoholprevention programs.

APPLYING HARM REDUCTION TO ALCOHOL USE
Although harm reduction often is thought of in the context of illicit drug use, the same principles can be applied to alcohol use. In fact, harmreduction measures are somewhat less controver sial for alcohol than for illicit drugs, if only because the use of alcohol gen erally is socially acceptable and legal (except under particular circumstances, such as while driving, and for those who are younger than the minimum drinking age). Therefore, although harmreduction and zerotolerance approaches differ sharply over the em phasis given to deterrence of illicit drug use, the parallel contrast between harmreduction and more traditional prevention approaches for alcohol is less distinct.
Until recently, public health advo cates in the field of alcohol prevention have tended to stress alcoholcontrol measures (e.g., restrictions on the na ture and extent of State monopoliza tion of alcohol trade, limits on the number and location of offpremises sales outlets, licensing regulations, drinkingage restrictions, proscriptions against selling to intoxicated patrons, advertising and sponsorship limitations, criminal penalties for driving while intoxicated, and alcohol taxation). This focus on restricting alcohol availability is based on the wellestablished rela tionship among alcoholcontrol meas ures, alcohol consumption levels, and indicators of alcoholrelated health and social problems (Bruun et al. 1975;Makela et al. 1981;Moore and Gerstein 1981;Edwards et al. 1994). As stated by Bruun and colleagues (1975), con trols over alcohol availability are justi fied on the grounds of public health: [O]ur main argument is well substantiated: changes in the overall consumption of alco holic beverages have a bearing on the health of the people in any society. Alcohol control meas ures can be used to limit con sumption: thus, control of alcohol availability becomes a public health issue (Bruun et al. 1975, pp. 12-13;italics in original).
In addition to alcoholcontrol meas ures, conventional alcoholprevention approaches have stressed a preventive education component primarily focused on the negative effects of alcohol con sumption. Generally, the message for all drinkers is unequivocal: Drinking less is better.
The message given through harm reduction approaches is different, although complementary: Avoid prob lems when you drink. This admonition does not contradict the message that drinking less is better. Indeed, some harmreduction approaches (e.g., the promotion of lowalcohol beverages) involve consuming less alcohol. Harm reduction differs from previous alcohol prevention approaches, however, in that it focuses on decreasing the risk and severity of harmful consequences arising from alcohol consumption with out necessarily decreasing the level of consumption itself. It is essentially a practical approach; success is not meas ured by the achievement of an "ideal" drinking level or situation (i.e., absten tion or lowrisk levels), but by whether the introduction of the prevention meas ure reduces the chance that adverse consequences will occur.
Harmreduction approaches to al cohol are neutral regarding the long term goals of intervention, which may or may not include abstention. The concept's defining feature is its attempt to minimize the negative consequences of alcohol consumption in situations where people will be drinking. The fact that drinking will occur is accepted, implying neither approval nor disap proval, and the drinker is held respon sible for his or her actions.

EXAMPLES OF HARM REDUCTION IN ALCOHOL PREVENTION AND TREATMENT
An excellent example of a harm reduction approach to alcohol is the introduction of special glassware into pubs in Scotland. When broken, this glassware crystallizes into fine parti cles. Therefore, if a fight develops, the combatants cannot smash a glass against the bar and use the glass shards as a weapon (Plant et al. 1996). Further examples of harmreduction measures to prevent adverse drinking conse quences are discussed below:

Measures That Directly or Indirectly Reduce the Consequences of Intoxi cation.
Along with the use of special glassware, this category includes ad justing the physical structure or lay out of drinking establishments (e.g., padding furniture and compartmental izing space) to minimize harm if a fight breaks out. Another example is the "Nez Rouge" ("Red Nose") program in Quebec, which is a community based service providing two drivers (one for the drinker and one for his or her car) to anyone who has had too much to drink at a party or at a licensed establishment to be able to drive home safely (Single and Storm 1985). In ad dition, many American cities now pro vide free public transportation on New Year's Eve and other festive occasions when heavy drinking is notorious for taking place. This category of harm reduction includes measures not specif ically aimed at reducing drinking con sequences, such as the introduction of airbags in cars, which decreases the number of alcoholrelated traffic in juries and fatalities.

Substitution of Less Intoxicating or
Damaging Beverages. In many coun tries, lowalcohol beverages, such as light beers, lowalcohol wines, and even light spirits, have been introduced and promoted in recent years. These beverages can reduce alcohol intake without affecting the overall volume of drinking (i.e., liquid intake). Thus, they maintain industry profitability and serve a public health purpose simulta neously. This category of harm reduc tion also includes substituting beverage alcohol for potentially dangerous alter native alcohol sources. For example, the Alberta Liquor Control Board in troduced special early hours for a store in downtown Edmonton to discourage severely alcoholdependent people from drinking potentially lethal non beverage alcohol (e.g., shoe polish). The measure was not intended to re duce alcohol consumption levels-in fact, it was expected to increase con sumption of drinkable (i.e., potable) alcohol; the measure was directed solely toward reducing the adverse consequences that result from drink ing nonbeverage alcohol. Server Training Programs. Server training also represents a harm reduction measure in several respects. Most server training programs involve the development of policies by drink ing establishments to promote modera tion (e.g., quality upgrading, in which higher price brands are promoted to reduce total alcohol intake; pricing bev erages with a lower alcohol content below higher strength beverages; and avoiding happy hours and other vol ume discounts or specials). They also may involve policies (e.g., designated driver programs) or environmental modifications (e.g., monitoring en trances to prevent underage or intoxi cated people from entering) to reduce the likelihood that alcoholrelated problems will occur. Staff are trained to recognize and gradually cease ser vice to intoxicated patrons, offering lowalcohol or nonalcoholic alterna tives instead. When these prevention efforts fail, servers also are trained to manage intoxicated patrons appropri ately (e.g., ensuring that they have safe transportation to get home). Thus, server training attempts to reduce drinking associated consequences without gen erally restricting drinking or adversely affecting the profitability of licensed establishments. In fact, evaluation studies (Geller et al. 1987;McKnight 1988;McKnight 1993;Gliksman et al. 1993;Homel et al. 1994; Saltz in press) typically have shown that es tablishments with serverintervention training tend to attract more customers and increase profitability as a result of introducing responsible serving practices. Server training programs currently are expanding beyond com mercial establishments to include social hosts who serve alcoholic bev erages. (For more information, see sidebar by McKnight, ControlledDrinking Programs. Some alcohol treatment programs do not require complete abstinence, but in stead train participants to control their drinking. Such programs generally are aimed at drinkers whose alcohol use is becoming a cause for concern because of alcoholrelated personal, employ ment, or health problems, rather than at severely alcoholdependent drinkers. Providing a controlleddrinking pro gram as a treatment alternative for people with alcohol problems might be considered a harmreduction measure, although it has been argued that harm from drinking is eliminated, not merely reduced, if drinking is controlled suc cessfully. In many ways, the often acrimonious debate concerning con trolled drinking versus abstinence as a treatment goal for people with alcohol problems parallels the conflict between harmreduction and zerotolerance ap proaches in druguse prevention. In each case, the former option makes allowances for (or at least tolerates) the continued use of alcohol or drugs, while the latter (i.e., abstinence and zerotolerance approaches) aims to halt use altogether.

FACTORS CONTRIBUTING TO A HARMREDUCTION TREND IN ALCOHOLPREVENTION PROGRAMS
Most of the examples of harmreduction measures presented in this article are relatively new and are part of a dis tinct trend toward prevention meas ures aimed at minimizing the negative consequences of drinking rather than decreasing drinking. Several factors contribute to this shift in alcohol prevention approaches.
One factor is declining political support for controls over alcohol avail ability in numerous parts of the world, especially in light of reduced alcohol consumption in many countries and the erosion of international trade bar riers. For example, although public opinion in Canada generally supports maintaining alcohol controls-such as alcohol monopolies, restraints on the number of retail outlets, and restrictions on advertising (MacNeil and Webster in press)-support for these alcohol control measures declined between the 1989 National Alcohol and Other Drugs Survey and the 1993 Canada's Alcohol and Other Drugs Survey. This trend will likely continue as new evi dence regarding the potential benefits of moderate alcohol consumption (see, for example, Klatsky et al. 1986;Moore and Pearson 1986;Stampfer et al. 1988;Klatsky et al. 1990;Klatsky et al. 1992;Poikolainen 1995)  the number of deaths averted by the moderate use of alcohol actually is greater than the number of deaths at tributable to alcohol in Canada; this finding will likely be the focus of publicity, even though it expresses only part of the research results. In response to declining support for alcohol controls, policymakers may give greater consideration to measures that emphasize minimizing the con sequences of drinking as opposed to measures that restrict access to alco hol. If this shift does take place, harm reduction approaches may receive increased attention, because they often focus on preventing problems associ ated with heavydrinking occasions (typically defined as having five or more drinks in a row), rather than per suading light and moderate drinkers to reduce their consumption level. The harmreduction perspective relies on environmental controls, such as serv er intervention and preventive educa tion, to convince drinkers at all levels of consumption to avoid risky drinking and to minimize any harm that may re sult from drinking.
In addition, empirical support ex ists for the focus on heavydrinking occasions. Analyses of national sur vey data in Australia (Stockwell et al. 1994), Canada (Single andWortley 1993), and the United States ) all indicate that it may be more efficient to focus on heavy drinking occasions rather than level of consumption. In these analyses, the level of consumption and the number of heavydrinking occasions were related to various indexes of alcohol problems. (In the Canadian analysis, for example, the alcohol problems examined included health complica tions, family discord, employment difficulties, financial strains, and drinkingrelated conflicts with the law.) Researchers consistently found that the number of heavydrinking occa sions more strongly predicted drink ing problems than consumption level.
Furthermore, an interaction effect takes place between the number of heavydrinking occasions and the level of consumption, with particularly high rates of alcohol problems among drinkers who generally consume low levels of alcohol but occasionally drink five or more drinks in a row. Table 1 presents data from the 1993 General Social Survey in Canada on the joint impact that the number of heavy drinking occasions and level of con sumption 1 have on one's likelihood of experiencing a drinking problem (Single et al. 1995). Light drinkers who drink immoderately (i.e., five or more drinks on a single occasion, for the purposes of this study) seven or more times per year show a greater likelihood of ex periencing drinking problems than heavy drinkers who rarely or never drink immoderately (17 percent versus 5 or 7 percent). This finding may be associated with physical tolerance as well as the tendency for heavy drinkers to develop social supports and other mechanisms to minimize the adverse consequences of their drinking. Of course, heavy drinkers can control the harmful consequences of alcohol con sumption only to a limited extent: Over time, heavy drinking greatly elevates the risk of chronic health consequences, such as cirrhosis. Nevertheless, for more acute alcohol problems (e.g., impaired driving, alcoholrelated family dys function, or employment difficulties), relatively light drinkers who occasion ally drink immoderately contribute substantially to overall problem levels.
To focus specifically on reducing the number of heavydrinking occa sions among all drinkers, programs can incorporate harmreduction approaches, such as environmental measures (e.g., serverintervention programs and im proved licensing enforcement) and preventive education (e.g., messages aimed at making intoxication and im 1 In this study, the cutoff points for different cate gories of drinking levels and heavydrinking occasions were empirically chosen such that the highest categories represented the top decile of respondents and the lowest categories repre sented the lowest 50 percent of respondents, with the middle categories falling between. Therefore, "light drinkers" were defined as those who consumed less than 52 drinks per year (i.e., an average of less than 1 drink per week); "moderate drinkers" consumed 52 to 364 drinks per year (i.e., an average of 1 to 7 drinks per week), and "heavy drinkers" con sumed more than 364 drinks annually (i.e., an average of more that 7 drinks per week). "Im moderate drinking" (i.e., a heavydrinking occa sion) was defined as consumption of five or more drinks on one occasion in the previous 12 months. "Alcohol problems" referred to ad verse effects on social life, physical health, happi ness, home life or marriage, work, or finances. paired driving socially unacceptable). These strategies differ from those focus ing on heavy drinkers or the total vol ume of alcohol consumed, but both types of approaches are important. Programs specifically targeting heavy drinkers (e.g., early identification and intervention programs) undoubtedly would help reduce alcohol problems. These and other programs aimed at reducing overall levels of alcohol consumption, however, should not be adopted to the exclusion of approaches that focus specifically on heavydrinking occasions. In fact, the findings previ ously described indicate that targeting preventive education to the general population may be most efficient (i.e., because people who consume alcohol at levels below those associated with alcohol dependence contribute substan tially to levels of alcohol problems). Specifically, such preventive education should emphasize safe drinking limits as well as the importance of avoiding intoxication and other problemcausing behaviors, rather than a person's over all level of consumption.
In sum, the trend in many coun tries toward harmreduction programs in illicit drugs is closely paralleled by a similar trend in alcohol prevention toward measures aimed at reducing the adverse consequences of heavy drinking occasions, albeit for different reasons. With the erosion of political support for alcoholcontrol measures and the emergence of new evidence about potential health benefits of mod erate drinking, this trend likely will con tinue. Future alcohol prevention may increasingly focus on reducing the harm ful consequences of alcohol use, rather than on monitoring personal consump tion levels to avoid dependence. ■